Dentists despair when they are forced to pull out rotten baby teeth, a tragedy they say happens far too often throughout New Zealand. Jane Phare reports on the state of Kiwi kids' mouths and what parents and caregivers can do to help.
Every year thousands of toddlers and young children go under general anaesthetic so that a dentist can pull out their rotten teeth. Some are still babies, not even turned 1 year old.
The statistics are grim. Around the country, roughly half of all Kiwi kids will have a cavity by the age of 5. That percentage is higher in poor communities and among Māori and Pasifika children.
Last year more than 8600 children aged zero to 17 had a general anaesthetic to have dental work done and teeth extracted, although that number includes children with special needs or behavioural difficulties. Many families go private, meaning hundreds more children are treated by paediatric dentists and oral surgeons under anaesthetic in private hospitals.
More than 3790 children and adolescents are on a public waiting list for hospital dental treatment and most of that work will be done under anaesthetic. Dentist and public health specialist Dr Rob Beaglehole calls the state children's teeth in 2022 "a scandal".
"It's crazy. It's the number one reason kids get admitted to hospital in New Zealand."
He's spent 25 years pulling out tens of thousands of tiny, rotten baby teeth.
"Brutal," he says. "It's carnage out there in terms of children's oral health."
Waiting lists soared after Covid-19 added an extra layer of stress on an already overburdened public dental service. Lockdowns and subsequent health restrictions meant dentists and dental services could not operate for prolonged periods. It means hundreds of Kiwi youngsters may not have had their teeth checked in more than two years at an age when soft baby teeth can deteriorate quickly.
The Auckland Regional Dental Service alone has 186,500 children up to the age of 12 (or Year 8) currently due for an appointment out of the 279,000 enrolled. Last year it cancelled 8600 appointments in the March/April level four lockdown, and another 12,000 in the August/September lockdown. The service was reduced to giving pain relief only.
The service's director Tim Wood doesn't like to talk in terms of a waiting list, but he does say that it will take more than a year to catch up with "the backlog". That delay will mean that inevitably hundreds more little teeth are in the process of rotting and cavities forming that parents and caregivers may not know about.
Parents whose children are in the public system are advised to be proactive to make sure their child is enrolled ready to be called for a check-up. New Zealand children are eligible for free dental care until the age of 18.
In theory, parents and caregivers should be contacted when children are around six months old, and looked after until Year 8. After that teenagers can go to a private dentist enrolled under the government scheme for free treatment. The Government has extended free dental treatment for another year for adolescents who turned 18 last year but were unable to access the service before their birthday.
But they, like other children and adolescents, may have to wait. The Auckland Regional Dental Service, and others throughout New Zealand, face a number of problems: a backlog due to Covid-19 lockdowns and health restrictions, a limited number of mobile dental vans and relocatable units, staff off work because they need to isolate due to Covid-19, and not enough staff to fill existing positions.
Hamilton paediatric dentist Katie Ayers is involved with five district health boards in the North Island and says in some regions children who need treatment will wait well over a year for an appointment.
"A substantial number of those children will have toothache, on and off, and antibiotics on and off."
Some district health boards are considering outsourcing groups of children or schools to private dental practices in an effort to catch up. Ayers, the access-to-care spokesperson for the New Zealand Dental Association, says Covid-19 restrictions since 2020 have meant the community dental service has no choice but to prioritise children with the greatest need, mainly low decile areas, Māori and Pasifika communities, and children who are very overdue for an appointment.
"What that means is there are some high decile schools (children) that haven't been seen for a long time either."
Ayers and other dentists around the country are seeing increasing numbers of parents bringing their children in for private dental treatment, rather than wait for a free appointment under the public system, and paying to have decayed teeth extracted in private hospitals. Some health insurance companies will cover children's dental work under anaesthetic.
Dr Katie Bach, a specialist paediatric dentist with Kidz-Teeth in Auckland's Meadowbank, regularly operates on children who need a general anaesthetic to receive dental treatment, including removing rotten teeth in 2- and 3-year-olds. In very young children she's seeing cavities caused by on-demand overnight feeding or by sucking on bottles in bed.
Bach has worked in both the public and private sector, training in Australian hospitals and working at Starship Children's Hospital before working in private practice. She sees children from all over the Auckland region, and from as far north as Whangārei. Decay in baby teeth is across all sectors, she says.
"Unfortunately it's really common in children in New Zealand, especially our younger children. It's difficult to clean their teeth. We've got lots of toddlers and pre-schoolers who continually graze throughout the day. Things can happen fast in little mouths."
Families are shocked to discover decay in their children's mouths and think they must be the only ones but Bach says they're far from alone. Parents should not feel guilty when they discover their child has tooth decay, she says.
"Nobody did this on purpose. Everyone is trying to do the best for their children."
She recommends three meals and two snacks a day and brushing children's teeth twice a day using a smear of fluoride toothpaste. As a parent of a 2-year-old, Bach is sympathetic about the demands of busy parents often trying to work from home.
The Covid-19 lockdowns made juggling parenting tougher and she admits giving her daughter Harriet the odd treat to keep her happy while working from home. Kidz-Teeth, like other practices, is flat out trying to catch up after last year's lockdowns led to hundreds of cancelled appointments.
But thousands of children whose families can't afford to pay for private treatment will have to wait. Staff shortages are making the backlog worse. In the Auckland region vacancies are between 30 and 40 at any one time out of the 350 staff, many of whom will retire this year. Wood says those staff shortages mean some dental chairs in the region remained empty in the service's 42 fixed clinics and 40 relocatable dental units. The service has extended its operating hours, including Saturday opening, in an effort to deal with the backlog but that puts additional strain on staff.
"We have to balance that so we don't burn out the workforce."
More mobile clinics would certainly help to deal with the backlog, Wood says, but then he wouldn't have enough staff to run them. The service tries to treat high-risk children twice a year, medium risk once a year and low risk every 18 months. But he admits there are children who will not be seen for longer.
One of the issues is getting informed consent from parents or caregivers to provide much-needed treatment and, in some cases, tooth extractions. The service has a team of staff dedicated to trying to track down guardians but Wood says families move around, and change their numbers and addresses regularly.
"We send a letter home with the children but it often doesn't get to the parents. And for many high-needs families, health care is quite low on their list of priorities compared to housing and food."
Dental staff frequently extract teeth that could have been saved if treatment had started earlier, he says.
Turn off the sugar tap
Beaglehole doesn't hold back when talking about the state of the nation's baby teeth, particularly as much of it is preventable. Sugary drinks and sweet treats are on the top of his hit list. Kiwis are the third-highest consumers of sugar per capita in the OECD, and sweet drinks are the number one source of sugar in the New Zealand diet up to the age of 30.
"Fruit juice will rip into your baby's teeth and it encourages that sweet taste. It's very acidic and it's packed full of sugar even though it might be natural sugars. Your tooth doesn't care whether it's Coke or juice," he says.
Up against 40 teaspoons of sugar in a 1.25-litre bottle of fizzy drink, Beaglehole doesn't think the dental service backlog will improve until the sugar tap is turned off.
"We have a tooth decay epidemic. There are so many kids out there with rotten teeth."
Artificially sweetened drinks like Diet Coke and Coke Zero are no better, he says, because they are so acidic and maintain a desire for sweetness. They won't cause cavities but they will gradually dissolve the teeth. Next on Beaglehole's list of causes is poverty.
"The lower down the socio-economic rung you go in terms of income, the worse off your oral health is. The gap between the haves and the have nots is shocking."
Why isn't the nation outraged, he wants to know? There is pain and suffering involved, and children can't concentrate at school. If baby teeth are forcibly extracted it can cause the adult teeth to grow back crooked. Beaglehole has taken out tens of thousands of children's teeth.
"And every time I do I feel sad that I've possibly affected their future smiles."
He wants the Government to step up and recognise the "appalling" state of children's teeth and the country's high sugar consumption. Check out breakfast cereals, he says, naming one popular brand that contains more sugar than ice cream.
"It's got four stars. It makes an absolute mockery of the health-star rating. And taxpayers are having to fix up the mess that they are causing."
In Beaglehole's sights is advertising and sponsorship promotion of sugary drinks, including sports drinks, that influence children and teenagers. Clamouring, too, is the Protect Kids from Junk Food Marketing group, a coalition of organisations including the Cancer Society, Health Coalition Aotearoa and the University of Auckland Medical and Health Sciences department, that wants the Government to introduce restrictions on advertisers and marketers, particularly those targeting children and teenagers during peak viewing times.
"The Government has done a world-class job at protecting us from Covid, announcing legislation around Smokefree 2025, and the fluoride bill," says Beaglehole. "But where's the national obesity reduction plan, where's the Government's sugar reduction plan?"
He favours a sugar levy on the soft drinks industry drink industry, modelled off a UK levy introduced in 2018, a move that led to massive amounts of sugar reduction in soft drinks.
For many years he's wanted to see primary and secondary schools adopt a water-only policy and stop selling fizzy drinks and fruit juice in tuck shops.
Fluoride bill won't be a quick fix
This month the Government made a move along those lines after Education Minister Chris Hipkins raised a proposal to ban sweet drinks in schools. Fluoridated water, too, is in the Government's sights after the passing of the Health (Fluoridation of Drinking water) Amendment Act which shifts the decision about fluoride in drinking water from local authorities to the Director-General of Health. But it's not likely to be a quick fix with many millions of dollars of fluoridation-related infrastructure still to be done in areas like Christchurch which have unfluoridated water.
The Ministry of Health has also been making gradual progress in enrolling children in the Community Oral Health Service, with data between 2007 and 2020 showing that enrolments of pre-school children doubled from 43 per cent to 93 per cent. The average number of decayed, missing and filled teeth per child at school in year eight (12-13 years of age) reduced by more than half, although improvements were not as good for Māori and Pasifika children.
Professor Jonathan Broadbent of the University of Otago is heartened by a Ministry of Health proposed initiative to distribute toothbrushes and fluoride toothpaste to children in schools, with a primary focus on low-income communities, and Māori and Pasifika children.
"Toothbrushes and toothpaste are supermarket commodities," Broadbent says. "You can't eat toothpaste so if you're struggling to put food on the table one of the first things that comes out of your shopping trolley is toothpaste."
But the prevention needs to start much younger than school age, he says. Broadbent, a dental public health specialist, has co-authored research that shows children who are breastfed (or bottle fed) beyond two years are more at risk of developing cavities.
"On-demand feeding for a newborn is very necessary. However, you need to give teeth a rest and so if you are breastfeeding beyond two years and the child has teeth it can be quite risky in terms of dental caries (decay)."
He is also the joint author of a paper published this year showing the importance of Vitamin D during pregnancy to aid the development of a baby's hard tissues.
"And teeth are a hard tissue. Vitamin D during the third trimester of pregnancy is important because that's when the teeth are developing. Once the child is born the teeth haven't come through yet but they (the teeth) are already developed."
Ten tips for healthy teeth
• Avoid sweet drinks, fizzy water and carbonated sugar-free drinks
• Fruit juice should either be avoided or diluted with 75 per cent water, and sipped through a straw
• Keep snacks to a minimum; three meals and two snacks a day is recommended
• Avoid "sticky" food like dried fruit or fruit bars that will stick to the teeth, and snacks high in sugar like biscuits, cake, muesli bars and sweetened yoghurts
• Avoid sweet toppings like honey, jam or chocolate spread
• Avoid putting a baby or toddler to bed with a bottle of milk or juice
• Brush baby's teeth daily with a soft toothbrush as soon as they appear
• Supervise brushing for two minutes with a smear of fluoride toothpaste twice a day until your child is at least 7
• Spit but don't rinse, leaving some of the fluoride toothpaste on the teeth
• Whenever visiting a health practitioner ask them to lift your child's lip to check for tooth decay